The Relationship between Clinical Supervision and Burnout in the Nurse’s Job ─ an Iranian Study

*Nursing & Midwifery faculty, Ilam University Of Medical Science, Ilam, IR-Iran.

Abstract

Background and Aim: Clinical nursing supervision is one way to support nurses in coping with their working situation and preventing burnout. The aim of this study was to establish the relationship between clinical supervision and levels of reported burnout in nurses in the Iranian state.
Material and Methods: This is a descriptive correlational survey design that was performed at the ILAM general hospitals, IR, during the year 2008. The research instruments which were used were the Maslach Burnout Inventory (MBI) and the Manchester Clinical Supervision Scale (MCSS). A sample of 120 registered nurses (RN) was enrolled into the study using a simple random sample method. Data were analysed using descriptive statistics, Pearson correlations and multiple regressions.
Result: Nurses reported moderate levels of effectiveness in clinical supervision in their workplaces, as well as moderate levels of burnout. Analysis showed that younger and male nurses were more likely to report cold negative attitudes towards their clients, as indicated by higher scores on the depersonalization subscale of the Maslach Burnout Inventory. Clinical supervision was significantly related to all burnout dimensions, most strongly to emotional exhaustion (r =-0.76, p<0.001) and depersonalization (r =-0.53, p<0.001). Emotional exhaustion and depersonalization were strongly negatively related to trust/rapport subscale (r =-0.58, P<0.001; r= - 0.42, p<0.001 respectively) and supervisor advice/support subscale (r = -0.52, P <0.001; r = - 0.40, p<0.001 respectively). Personal accomplishment was strongly positively related to supervisor advice/support subscale (r = 0.37, p<0.05). Also, there were significant correlations between the all MCSS and the all MBI subscales (p<0.001, p<0.05)
Discussion and Conclusion: Higher levels of clinical supervision were associated with lower levels of burnout .These findings suggest that if clinical supervision is effective, then nurses are likely to report lower levels of burnout. Further research is required to determine the long-term benefits of implementing clinical supervision, and to determine which other factors have an influence on levels of burnout for nurses. These findings have important implications for nursing education administrators.

Introduction
The future challenges of health care are to provide high quality services to respond to the changing needs of the population, and to provide for the well being of the health care personnel (1). Clinical supervision (CS) is ‘a formal process of professional support and learning’, which enables individual practitioners to develop knowledge and competence, assume responsibility for their own practice and enhance consumer protection and safety of care in complex clinical situations (2). According to Severinsson (1990), supervision also helps healthcare professionals to maintain their ability to take action under stress and to adopt a more tolerant attitude towards patients (3).

The goal of administrative clinical supervision emphasizes quality management based on the organization’s mission and vision statements, in addition to the supervisee’s learning, in order to support career development (1). Poor nursing supervision and management are associated with poor clinical outcomes, increased staff turnover, and reduced retention among the nursing staff (4).

Previous research shows that the most common reason for long-term sick leave is depression, caused by exhaustion and burnout (3). Also, high levels of stress and burnout have been identified in nurses. Nurses are considered to be particularly susceptible to burnout. According to two European epidemiological studies, burnout affects approximately 25% of all nurses (5). Clegg (2001) has suggested that supervision is widely discussed as a means of helping people to avoid burnout and job-related stress, and to improve clinical performance (6).
Clinical nursing supervision (CNS) is one way to support nurses in coping with their working situation and in preventing burnout (7). CNS is an ongoing systematic process that encourages and supports improved professional practice (8). Coffey and Coleman (2001) have suggested that effective structures for clinical supervision are a necessary means of providing staff support for community mental health nurses (9). Previous research on the effects of clinical supervision shows that clinical supervision influences the quality of care, and thus can be considered as an intervention that improves the quality of nursing practice (10). In addition, evidence reported by Booth (1992) indicates that improved staff morals and reduced absenteeism results in a higher standard of patient care (8).

Proctor (1991) asserted that supervision has three main functions: normative, formative and restorative. Normative supervision means giving advice designed to promote high quality care and to reduce risks. Formative supervision is concerned with helping nurses to develop their skills and update their knowledge base. Restorative supervision means giving personal support to help supervisees cope better with the pressures of their work (11).

Perceived benefits of CNS are improved patient care, stress reduction, enhanced skills and job satisfaction (12). The findings of a Norwegian study revealed that nurses attending supervision experienced stress and perceived their shortcomings to a higher degree (13). However, a Swedish study found that health care professionals who received CNS as a support in their clinical nursing work perceived that they felt more secure in decision-making, as well as safer, in their relationship with patients (14). Restorative and supportive outcomes of CNS in Finland have been described in terms of reduced stress, less burnout and decreased workload as a result of a more organized approach to work (12).

There is a growing awareness of and commitment to the value of clinical supervision and the supervisory relationship (2). A number of Scandinavian and British studies have investigated the relationship between clinical supervision and burnout (15),(16),(2), (11).

Berg et al. (1994) found that the degree of burnout experienced by nurses in receipt of clinical supervision, decreased significantly (15). Butterworth et al. (1997), in a quasi-experimental design, found that nurses in the control group who received no clinical supervision, were found to have increased levels of burnout; when this same group received clinical supervision during later phases of the study, levels of burnout were found either to stabilize or decline. Nurses in the experimental group who received clinical supervision from the start of the study, showed no alteration in burnout (2).

Palsson et al. (1996) found no significant effect of supervision on burnout (16). Clinical supervision was found to have no effect on levels of burnout in the study by Teasdale and colleagues (11).

In summary, however, the findings from the evaluative literature concerning the relationship between clinical supervision and burnout are, that contradictory levels of burnout following participation in clinical supervision have showed either no change (16),(11) or stabilization and/or reduction (15),(2).Winstanley (2000) suggests that if clinical supervision is effective, then levels of burnout may be lessened (17).

The aim of this study was to establish the relationship between clinical supervision and levels of reported burnout in nurses in the Iranian state. It was hypothesized that higher scores on the Clinical Supervision may be associated with lower levels of measured burnout.

Material and Methods

This is a correlation study that was performed at the ILAM hospitals, IR, during the year 2008. The study was approved by the institutional review board. The research instruments used were the Maslach Burnout Inventory (MBI)(18) and the Manchester Clinical Supervision Scale (MCSS)(17). A demographic questionnaire was also distributed, and the items included age, gender, marital status and work experience.

Maslach Burnout Inventory is a 22-item measure consisting of three independent subscales: emotional exhaustion (EE), depersonalization (DP) and personal accomplishment (PA). The EE subscale consists of nine items, the DP subscale five items and the PA subscale eight items. Respondents were asked to rate items on a scale of 0 = never to 6 = every day. From these frequencies, mean scores were obtained for each of the three subscales. For the emotional exhaustion and depersonalization subscales, high mean scores reflect high levels of burnout, while for the personal accomplishment subscale, low scores reflect high levels of burnout. Respondents were allocated to a ‘high burnout’, ‘average burnout’ or ‘low burnout’ category for each of the three subscales. The Maslach and Jackson (1981) report showed an acceptable reliability for all subscales (EE = 0.90, DP = 0.79, and PA = 0.72)(19). In this study, the alpha reliability coefficients were 0.87, 0.72 and 0.70 for the EE, DP and PA subscales, respectively.

The MCSS is a 36-item questionnaire with a Likerttype (1–5) scale, comprising 7 sub-scales: trust and rapport (TR), supervisor advice and support (AS), improved care and skills (IC), importance and value of clinical supervision (IV), finding time (FT), personal issues and reflection (PR) and total score. Each item is rated on a rating scale from strongly disagree (1=strongly disagree) to strongly agree (5=strongly agree). The rating scores are summated by sub-scales. A high score for any subscale reflects a high degree of effectiveness of the clinical supervision process. A high total evaluation score reflects a high level of overall effectiveness of the clinical supervision process (20). In this study, the alpha reliability coefficients for MCSS were 0.80, 0.82, 0.87, 0.68, 0.66, 0.71 and 0.90 for the TR, AS , IC, IV, FT,PR and Total evaluation score, respectively.

The aim of the instrument is to measure the efficiency of, and satisfaction with, the supervision received from the supervisees’perspective, to investigate the skills acquisition aspect of clinical supervision and the effect on the quality of clinical care (17).

The target population comprised of all nurses working in 3 general hospitals within ILAM. A simple random sample of 120 registered nurses (RNs) was selected. The research instruments, along with a demographic questionnaire, were distributed to nurses. Descriptive and inferential statistical analyses were performed using the Statistical Package for Social Sciences Program Version 11.5 (SPSS). Multiple regression analysis and Pearson correlation analysis were used to test the study hypotheses.

Results

The mean age of those who completed the questionnaires, was 32 (±6) years, and 85(70.8%) were women. The mean work experience of the nurses was 9.4(±6.6) years, and 80(66.7%) were married. Mean values and the SD for major study variables are shown in [Table / Fig 1]. (Table/Fig 1) shows the subscale and total scores on the MCSS for all respondents. The nurses perceived that Clinical Supervision in their work environment contributed to moderate effectiveness in their work. (M = 120.42, SD = 12.64).

According to Maslach’s norms, the nurse’s levels of EE, DP and PA were moderate (M = 22.64, SD = 11.54; M = 7.60, SD = 4.35; M = 33.24, SD = 5.30; respectively) (Table/Fig 1).

This study found that there were significant negative correlations between the total MCSS score and the emotional exhaustion subscale (r = -0.76, P< 0.001), depersonalization subscale (r=-0.53,P< 0.001) and positive correlation between the personal accomplishment subscale and total MCSS (r=0.41,p<0.001). Emotional exhaustion and depersonalization was strongly negatively related to the trust/rapport subscale (r = -0.58, P < 0.001; r= - 0.42, p<0.001 respectively) and the supervisor dvice/support subscale (r = -0.52, P <0.001; r = - 0.40, p<0.001 respectively). Personal accomplishment was strongly positivly related to the supervisor dvice/support subscale (r = 0.37, p<0.05) and the trust/rapport subscale (r = 0.33, p< 0.05). Correlations between the MCSS and the MBI subscales are presented in (Table/Fig 2). There were significant correlations between all MCSS and all MBI subscales (p<0.001, p<0.05).(Table/Fig 2).

The possible relationships between the burnout subscales and a number of items on the demographic questionnaire were investigated. There was a significant negative correlation between age and depersonalization (r= -0.24, p<0.05), and a significant association between depersonalization and gender (p<0.05). Those nurses who were younger and were males had higher burnout for depersonalization.

Discussion

The findings from the present study are consistent with the findings from previous studies by Edwards et al (2006) (2), Jenkins et al (2004)(21), Kilfedder et al (2001)(22), and Edwards and Burnard (2003)(23), that have used the MBI to investigate levels of burnout within nurses. Robinson et al. (1991) as well as van Servallen and Leake (1993) found using the Maslach Burnout Inventory, that young staff members experience more emotional exhaustion and depersonalization, but that in old staff members personal accomplishment was low(24). Nurses perceived that there was moderate effectiveness in their work environment after clinical supervision (M =120.42, SD=12.64).

The aim of this study was to establish the relationship between clinical supervision and levels of reported burnout in nurses. Findings from previous research have been contradictory, with no clear evidence of the effectiveness of supervision emerging, for the mental health of general nurses. Teasdale et al. (2001) indicated that clinical supervision did not offer protection against burnout for a sample of general nurses (11). However, Severinsson and Borgenhammar (1997) and Edwards et al (2006), indicated that clinical supervision decreases burnout and increases work satisfaction, as well as improves the staff’s qualifications in providing good patient care (11),(24).

Edwards et al (2006), on further analysis of the MCSS subscales and subscales of the MBI, found that finding time for the clinical supervision sessions in a busy work schedule may lead to increased levels of burnout for emotional exhaustion and depersonalization. Being able to discuss sensitive and confidential issues with supervisors may lead to lower levels of burnout for emotional exhaustion and depersonalization. In addition, feeling supported by the supervisor and having a positive attitude towards clinical supervision may lead to lower levels of burnout for depersonalization (2).
Butterwood and Woods (1999) emphasised the importance of the joint responsibility for implementing and maintaining clinical supervision between individual clinicians and institutions (2). In recent years, Finnish hospitals have provided more clinical supervision for their staff. In Finland, clinical supervision refers to staff development after vocational education under a specially trained supervisor, either on a group or individual basis. The possibility provided by clinical supervision to deal with stress and problems, is a factor that is assumed to have an effect on staff burnout (24).

Health service organizations have a responsibility for ensuring that all individual practitioners have access to effective clinical supervision. Organizing and participating in clinical supervision are best seen as activities which are part of the wider clinical governance framework, alongside other quality-enhancing activities such as clinical audit, clinical risk management and evidence-based practice. To enhance this, the Nursing and Midwifery Council could extend the registered nurses, personal accountability to include – to seek clinical supervision as and when necessary.

Findings from our study are important, with implications for service organization and the delivery of high-quality health care. The findings from this study suggest that if clinical supervision is effective, then nurses report lower levels of burnout. Further research is required to determine the long-term benefits of implementing clinical supervision, and to determine what other factors have an influence on levels of burnout for nurses over an extended period of time.

Acknowledgement

We thank the staff of ILAM hospitals for providing the necessary support for successfully completing this study.